CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 445 241.000000 8965.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1521 7059.750000 263543.4000 37.3304
Subtotal (Total Children Is Unduplicated) 1748 7301.750000 272508.6000 37.3210
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 34 43.000000 2085.5000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 15.8400 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 63.6200 31.8100
EXIT-EXIT-COS Exit 372 356.250000 18137.5000 50.9123
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 119.8600 59.9300
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 7 10.000000 599.2000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 292.9700 58.5940
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 283.4300 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.500000 1108.4300 76.4434
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 23.500000 1528.1600 65.0281
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 692.9400 76.9933
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 655.4400 77.1106
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 60.000000 3263.1500 54.3858
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 37.500000 2101.1400 56.0304
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 47.500000 3613.3300 76.0701
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 32.000000 2392.6500 74.7703
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
SPCH-92521-EVAL OF SPEECH FLUENCY 2 15.000000 871.6500 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 109.5200 54.7600
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 102.9700 51.4850
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 19.000000 1030.3900 54.2311
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 3 13.000000 735.3300 56.5638
Subtotal (Total Children Is Unduplicated) 512 740.750000 42147.2800 56.8981
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 477 607.500000 30339.0000 49.9407
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 432 608.000000 30462.5000 50.1028
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 155 154.250000 3956.7500 25.6515
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 262 776.000000 38800.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 286 1254.750000 53237.5000 42.4288
CONIP-CONIP-CONSULT, ITDS PHONE 38 61.500000 1587.5000 25.8130
CONOF-CONOF-CONSULT, OT, FACE TO FACE 61 139.750000 6987.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 153 535.250000 26762.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 25 39.250000 981.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 78 121.250000 6062.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 136 435.500000 21775.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 25 49.250000 1256.2500 25.5076
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 200 558.750000 24734.4600 44.2675
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 168 546.000000 27300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 40 53.500000 1437.5000 26.8692
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 162.0000 54.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 322 3025.500000 159512.0000 52.7225
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 69 385.250000 20104.5000 52.1856
EPIC-99601-Early Steps Professional Development Fee 403 6573.000000 98595.0000 15.0000
INTR-T1013-INTERPRETER 214 713.750000 35541.1000 49.7949
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1879 38689.00000 464268.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 104.500000 8376.2600 80.1556
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 8 19.000000 1507.6400 79.3495
PHY-97110-PT SESSION BY LICENSED PT 45 383.250000 27647.4200 72.1394
PHY-97110GPGT-PT SESSION BY LICENSED PT 1 3.000000 243.9600 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 6 46.000000 3672.8400 79.8443
PHY-97110TL-PT SESSION BY LICENSED PT 2 12.000000 957.1200 79.7600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 320.750000 23674.1200 73.8086
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 37.000000 2924.6000 79.0432
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 17.000000 1107.0400 65.1200
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 6.000000 390.7200 65.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 11.750000 899.3500 76.5404
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 243.9600 81.3200
SPL-92508HA-GROUP SPL SESSION PER CHILD 4 12.000000 166.6400 13.8867
CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TRAV-TRAVS-Travel by mile 569 122261.0000 54474.2900 0.4456
Subtotal (Total Children Is Unduplicated) 2320 178569.2500 1180392.7300 6.6103
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Total 186611.750000 1495048.6100 8.0115
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Number of Children (Unduplicated) With at Least One Service 2948
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Center 01
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 58314 153683.250000 1025203.6400 1025138.4600
D 927 2232.000000 18750.6200 0.0000
S 16 15.000000 525.0500 0.0000
H 0 0.000000 0.0000 0.0000
T 6473 21989.000000 104017.0800 103910.5300
12327 8692.000000 346533.6200 0.0000
Other 1 0.500000 18.6000 0.0000
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Total 78058 186611.750000 1495048.6100 1129048.9900